In a nation celebrated as the “pharmacy of the world,” where medical advancements coexist with ancient healing traditions, millions of ordinary Indians still struggle with the simplest of health needs

You walk into a chemist shop with a simple prescription one tablet, maybe two. The pharmacist looks you and says, “We do not sell one tablet. You have to buy the whole strip.” There is no room for discussion. You are forced to pay for more than you need, knowing some of it will expire unused in a corner of your cabinet. You leave, annoyed, not just at the pharmacist but at a system built to bleed the sick.

This is not an isolated incident. It is how the pharmaceutical business operates, built not around patients but around profit. Why can you not buy a single tablet? Why does a medicine that costs `13 at the factory gate sell for `130 at the counter? How is this allowed in a country where so many struggle to access basic healthcare? People are routinely cornered into making impossible choices, medicine or meals, prescriptions or school fees. In a country that boasts of medical advancements and world-class drug manufacturing, the harsh truth is this: access to affordable medicine is a myth for the average Indian.

Generic drugs, meant to be the great equaliser, are no better. The transparency is nonexistent. Medicines manufactured cheaply are sold with little accountability. Chemist shops refuse to break a strip. Doctors scribble illegible prescriptions, sometimes linked to incentives from pharmaceutical companies. The authorities that are meant to regulate and protect, like the NPPA, have remained largely ineffective in fixing this rot. This is not a flaw in the system. This is the system. Designed to prioritise margins over lives, packaging over patients, and commerce over care.

Jan Aushadhi Kendras are being opened under Pradhan Mantri Bhartiya Janaushadhi Pariyojana claiming a huge saving to commoners ranging from 50-90 per cent on purchase of generic medicines from these about 10000 centres throughout the country with average monthly sale of just `1.50 lakhs per month for each centre. Much more can be achieved by fixing a maximum trade margin on all medicines and medical-consumables including generic medicines of say 30 per cent between ex-factory price and Maximum-Retail-Price (MRP).

Same is case with thousands of generic medicines manufactured by various companies Even branded medicines had varying trade-margins with a box of 10 strips of 10 capsules each of Bifilac-HP with total printed MRP of rupees 2300 per box was available at rupees 1350 per box. World Health Organisation established that essential drugs in India with lowest printed MRP are exorbitantly priced over manufacturing-cost followed by abnormally high trade-margin between ex-factory price and MRP. Same holds good for other medical-consumables like a box of 200 Accu-Check Safe T Pro Uno single-use lancing device with printed MRP of `2200 used to be available at just `600 only.

Drug-manufacturers at times pack just eight lozenges per strip of commonly advertised cough-medicines instead of usually ten because consumers judge by price per strip rather than per lozenge.

Many drug-manufacturers have started packing medicines in strips of fifteen rather than earlier ten to boost up sale because most chemists sell complete medicine-strip rather than cutting the strip to sell in loose. National Pharmaceutical Pricing Authority (NPPA) should direct all medicines to be packed in units of 1, 2, 5, 10, 20, 50, 100, 200, 500, 1000 and higher multiples unless permission. Name of medicine is usually printed just once on a side of medicine-strip. Wrapping-foil must be so designed that name of medicine may appear for each packed tablet/capsule with name of medicine also embossed/printed on each tablet/capsule.

Ex-factory prices of different branded medicines for same basic salt has vast difference. Branded medicines from different renowned companies are priced with heavy difference depending on popularity of brand like Calmpose and Valium-5 both having Diazepam-5 as basic salt have huge price-difference. Medicines are put in different categories for price-regulation with Calmpose and Valium-5 put in a category where there is no price-regulation. System of having multiple categorisation for medicines must be removed because patients have to take prescribed medicine irrespective of their categorisation.

A study conducted by a prominent newspaper in the year 2018 revealed that five chemist-shops around Post Graduate Institute of Medical Education and Research (PGIMER) at Chandigarh were selling a particular medicine having price ranging from `255 to `1550. NPPA should devise a mechanism whereby drug-companies may be allowed to have some basic profit-margin on all types of drugs irrespective of their categorisation allowing any price-revision only once in a year say in January or April every year. Madras High Court once directed Income Tax Department to submit details of claims made by pharmaceutical-companies towards tax-deduction for gifts made to doctors. Any type of gifts by drug-companies must be banned.

Paying commission to medical practitioners by pathological laboratories, investigating centers and hospitals should be criminal offence to ensure economical medical investigations. Private hospitals should be directed not to take any share from consulting/visiting fees of medical practitioners. Some upper limit should be fixed for consultation-fees of medical practitioners. Since wholesale medicine-market of Bhagirath Palace (Delhi) has virtually turned to be a retail market giving 20-25 per cent discount even on single strips of medicines, tenders can be invited for opening chemist-shops in Government and private hospitals at least in big cities where branded medicines may be available even in single strips at 20 per cent discounts.

Some medical-practitioners including in Unani, Ayurvedic and Homeopathic fields mix strong doses of allopathic steroids in unbranded medicines like powders and syrups in a bid to exhibit their self-acclaimed expertise in curing diseases. Only branded medicines should be allowed to be prescribed in all fields of medicines including Allopathic, Ayurvedic, Unani, Homeopathy with Central Government having its large production-units for very type of medicines by reviving Indian Drugs & Pharmaceuticals Limited (IDPL) in a big way and popularising and extending scope of its Ayurvedic unit Indian Medicines Pharmaceuticals Corporation Limited to develop a healthy competition to force big drug-companies to bring down heavily prices of branded medicines. Central Information Commission in its order dated 01.10.2018 in case CIC/ NPPAT/A/2017/152869 -BJ recommended NPPA and others concerned to consider all these suggestions in larger public interest. But NPPA challenged the CIC-decision just on recommendations (and not directions) at Delhi High Court vide WP(C) 10366 of 2019 and CM No. 42777 of 2019. Soon after Competition Commission of India (CCI) in its policy-note also pointed out towards unreasonably high trade-margins as reason for exorbitant drug-prices. But no corrective measures are seen at least on non-essential and generic medicines.

BJP MP Bhartruhari Mahtab raised issue of generic drugs in Lok Sabha on 19.07.2019, rightly demanding an inquiry to find out the efficacy of generic drugs quoting a book-study that Indian drug manufacturers were producing quality generic medicines for US and European countries with sub-standard generic medicines marketed in domestic market. NPPA should ensure that generic medicines sold in Indian markets are of export-quality. Export of world-class generic medicines can provide country adequate foreign-exchange and reputation because of Indian generic medicines are economical than foreign-branded medicines. Lucknow bench of Allahabad High Court in the year 2018 imposed fine on three doctors for illegible hand-writing on injury-reports. Odisha High Court on 13.08.2020 advised doctors to write legible prescriptions preferably in capital letters. Medical-practitioners should compulsorily issue computerised prescriptions. Union Health Ministry should develop user-friendly softwares separately for hospitals, pathological laboratories and medical practitioners providing unique ID for each patient so that complete medical history may be available even online to the patient. Dual pricing must not be allowed in health-services including for pathological and biochemical tests for normal patients and those covered under Central Government Health scheme. All hospitals getting land at subsidised cost/lease from Governments should be declared as public-authorities under section 2(h) of RTI Act, or else pay market-price of land provided to these hospitals at market rates.

The whopping price difference

There is a huge trade-margin specially on generic medicines considered to be economical substitute of branded medicines. A box of 10 strips is at times available with distributors at about one-tenth of printed MRP. Following table depicts comparison of wholesale price and Maximum-Retail-Price (MRP) of generic medicines

— The writer is a RTI consultant. Views expressed are personal